Due to the current COVID‐19 outbreak and in an attempt to protect the safety and minimize the risk of potential exposure to our staff and clients, additional steps are being taken as it relates to the Clinic Clients. Please read and acknowledge, via signature, the statement and information below.

First	*
Last
Phone	*
Email	*
Address:	*
Do you have a fever, cough, shortness of breath or difficulty breathing?	*	YES NO
In the last 14 days have you traveled outside of Virginia (DC METRO) ?	*	YES NO
Have you had any contact with a confirmed or probable case of COVID-19 or person with acute respiratory illness (fever, cough, shortness of breath) who has travelled outside of Virginia (DC METRO) in the last 14 days?	*	YES NO
Do you have two (2) or more of the following symptoms below?	*	YES NO
 Sore throat  Hoarse Voice  Difficulty swallowing  Decrease or loss of sense of taste/smell  Chills  Headaches  Unexplained fatigue/malaise  Diarrhea  Abdominal pain  Nausea/vomiting  Pink eye (conjunctivitis)  Runny nose/sneezing without other known cause  Nasal congestion without other known cause
NOTE - If you pass the screening you will be provided a mask if you do not have one that you must wear while at the Clinic and in the building. Should you have a fever or present any symptoms marked above, your appointment will need to be rescheduled until you am safely outside of the stipulated parameters and/or you are no longer experiencing any symptoms of illness.
Signature Acknowledgement (Type Name)	*
Security Code	*